Medical Decision-Making

Medical decision-making coding includes the number of diagnoses and treatment options, the amount of data and the complexity of data and risk.

Diagnosis and treatment options: 

• New problem – a problem new to the physician 

• Established problem, stable – a known diagnosis that is stable 

• Established problem, worsening – a known diagnosis that is worse 

• Established problem, improved – a known diagnosis that has improved 

• Work-up planned – a new complaint for which additional work-up is planned 

• No work-up planned – new complaint(s) for which no additional work-up is planned

Coding for the amount and complexity of data component is composed of the following information, which is obtained, ordered or reviewed during the encounter:

• Review/order lab tests 

• Review/order routine x-rays 

• Review/order test from medicine section 

• Discuss test results with performing physician 

• Decide to obtain old records and documents 

• Document direct visualization and independent interpretation

The risk component is composed of the present problem, diagnostic procedure or management option. The risk is determined by the component of the highest level to determine the overall risk for the patient.

Presenting problems are described as: 

• Minimal – one self-limited or minor problem 

• Low – two or more self-limited or minor problems, one stable chronic illness or one acute uncomplicated illness/injury 

• Moderate – one or more chronic illness with mild exacerbation, two or more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms or acute complicated injury 

• High – chronic illness with severe exacerbation or acute or chronic illness/injury that may pose a threat to life or bodily function

The component for diagnostic procedures ordered is described as: 

• Minimal – lab tests requiring venipuncture, x-rays, ultrasound 

• Low – superficial needle biopsies, skin biopsies, PFTs

• Moderate – diagnostic endoscopy, deep needle or incisional biopsy 

• High – diagnostic endoscopy with risk factors

Management options are described as:

 • Minimal – rest, gargles, elastic/superficial dressings

 • Low – over-the-counter drugs, saline washes, minor surgery, physical therapy

 • Moderate – minor surgery with risk, elective major surgery, prescription drug management

 • High – elective major surgery with risk, emergency major surgery, decision not to resuscitate or de-escalate care because of poor prognosis, drug therapy requiring intensive monitoring for toxicity, high morbidity and mortality without treatment

The level of medical decision-making depends on the number of diagnoses, the amount and complexity of the data and the risk. The appropriate level is determined by choosing the level where the middle component rests, or where two out of three of the components meet. For example, a new patient presents with asthma and allergic rhinitis. The patient is allergy tested, has a PFT and is placed on a prescription medication. The appropriate level of medical decision-making would be moderate for this patient. If a comprehensive history and a comprehensive exam were also performed and documented, the physician would code for a 99204 level of service.